Social determinants of health that impact the time to diagnosis and treatment of infertility in Taiwan.

BACKGROUND/PURPOSE: Taiwan is one of the countries with the lowest birth rate in the world. We investigated factors associated with the time to diagnosis and treatment of infertility in Taiwan. METHODS: The study was conducted through an online questionnaire in December 2021. The questionnaire was adapted from a previously published multinational survey, and culture-specific questions were added. 91 infertile patients and 89 partners of patients in Taiwan, aged 20- to 45- year-old, were included. RESULTS: The average duration before diagnosis was 2.9 years, followed by 1.5 years before treatment. Older age at marriage (p = 0.0024), higher education level (P = 0.0001), and a higher gender equality score (p = 0.0031) were associated with earlier diagnosis. Conversely, folk therapy use was linked to later diagnosis (p < 0.0001) and treatment (p < 0.0001). Notably, in the female (p = 0.039) and patient (p = 0.0377) subgroups, a higher gender equality score was associated with a shorter duration of folk therapy. Subjectively, the most frequent factor influencing treatment decision was affordability or lack thereof. The government subsidy for in vitro fertilization led to increased treatment willingness for 46.3% of respondents, and 47.3% reported more likely to pursue earlier treatment. CONCLUSIONS: This study highlights the influence of education, gender equality, folk therapy, and government subsidy on fertility care decisions. To improve the timeliness of infertility healthcare in Taiwan, potential strategies include promoting education, fostering gender equality, providing financial support, and raising awareness on the association between folk therapy and delayed medical care.

Comparison of miscarriage rates in low prognosis patients according to the POSEIDON criteria.

OBJECTIVE: The POSEIDON criteria stratified patients with poor ovarian response into four subgroups with exclusive characteristics and assisted reproductive technology success rates. However, limited studies focused on miscarriage in the POSEIDON population. This study aimed to explore whether the miscarriage rate different among low prognosis patients according to POSEIDON criteria. MATERIALS AND METHODS: This is a retrospective observational study. All clinical pregnancies achieved after in vitro fertilization or intracytoplasmic sperm injection treatment between January 1998 and April 2021 were analyzed. The primary outcome was miscarriage, defined as the pregnancy loss before 20 weeks of gestation age. Miscarriage rate was estimated per clinical pregnancy and gestational sac. RESULTS: A total of 1222 clinical pregnancies from 1088 POSEIDON patients met the inclusion criteria. The miscarriage rates per clinical pregnancy in each POSEIDON subgroup were as follows: Group 1: 11.7 %, Group 2: 26.5 %, Group 3: 20.9 %, and Group 4: 37.5 %. The miscarriage rate per gestational sac showed a similar trend as the clinical miscarriage rate. Multivariate regression analysis showed that advanced maternal age is an independent factor for miscarriage (Group 2 vs. 1: OR 2.476; Group 4 vs. 3: OR 2.252). Patients with diminished ovarian reserve (DOR) have higher miscarriage risks but without significance (Group 3 vs. 1: OR 1.322; Group 4 vs. 2: OR 1.202). CONCLUSION: Miscarriage rates differed among low prognosis patients according to the POSEIDON criteria. Age remains a determined risk for miscarriage. DOR might be a potential factor for miscarriage, but it didn't account for a significant impact in POSEIDON patients.

Unscarred uterine rupture with catastrophic hemorrhage immediately after vaginal delivery: diagnosis and management of six consecutive cases.

BACKGROUND: To describe and explore the risk factors, clinical presentations, timely diagnostic approaches, and management in patients experiencing unscarred uterine rupture with catastrophic hemorrhage. METHODS: We retrospectively analyzed clinical and imaging data from women who encountered postpartum hemorrhage (PPH) and were diagnosed with unscarred uterine rupture within a three-year timeframe (2018-2020). The data were extracted from medical records obtained from a multi-hospital 24-hour emergency PPH transfer system. RESULTS: Six patients were identified as having unscarred uterine rupture after vaginal delivery. All six women were para 2, with four of them undergoing vacuum-assisted delivery. One patient experienced out-of-hospital cardiac arrest (OHCA), while five patients presented with hypovolemic shock. Abdominopelvic ultrasound revealed a boggy lower uterine segment. Initially, five patients underwent transarterial embolization (TAE) of the internal iliac arteries in an attempt to achieve hemostasis, but this approach proved unsuccessful. Abdominopelvic computed tomography (CT) confirmed the diagnosis of ruptured uterus by demonstrating disrupted myometrium and hemoperitoneum. Immediate exploratory laparotomy followed by life-saving hysterectomy was performed in all cases. The median estimated total blood loss was 2725 mL ± 900 mL (ranging from 1600 mL to 7100 mL). Lower segment lacerations were observed in all patients, with more extensive uterine damage noted in those who underwent vacuum extraction. The length of hospital stay varied between 9 and 38 days. CONCLUSION: Instrument-assisted obstetric delivery is a possible contributing factor to unscarred uterine rupture in our study. In specific cases, the use of abdominopelvic CT prior to initiating transarterial embolization (TAE) offers valuable information to complement ultrasound findings. This comprehensive approach helps in accurately identifying the underlying cause of intractable postpartum hemorrhage (PPH). Immediate conversion to laparotomy is essential to explore the intra-abdominal factors causing PPH that cannot be controlled by TAE. The rational etiologies of uterine rupture must be clarified while generating practical guideline in the future.

High-grade endometrial stromal sarcoma in cesarean section scar isthmocele - case report.

OBJECTIVE: Cesarean section scar defect isthmocele, the pouchlike defect in the anterior uterine wall of the prior cesarean site. No previous report of malignant neoplasm in the isthmocele have been published. We reported a case of High-grade endometrial stromal sarcoma in isthmocele. CASE REPORT: A 45-year-old patient with gravida 4, parity 2, two previous cesarean section presents of recurrent heavy vaginal bleeding. Curettage and hormone therapy were unsuccessful. She underwent hysteroscopic isthmoplasty. The pathology revealed high-grade sarcoma. Patient was referred to a tertiary medical center and she underwent total hysterectomy with bilateral salpingo-oophorectomy, aortic & pelvic LNs dissection. The final diagnosis was High-grade endometrial stromal sarcoma (HG-ESS) stage IA (pT1a N0) involving isthmocele. CONCLUSION: The presence of this rare tumor in the isthmocele is very interested. We stress the necessity for a high degree of suspicion to diagnose the malignancy in perimenopausal women with isthmocele and persisted abnormal uterine bleeding.

A novel approach with concomitant laparoscopic uterine artery ligation and D&C as initial treatment for complicated gestational trophoblast disease in cesarean scar and cervical ectopic pregnancies.

OBJECTIVE: Gestational trophoblast disease (GTD) in low-lying implantation ectopic pregnancy (LLIEP) is extremely rare. Surgical removal of GTD lesions which is the initial treatment of choice carries a high risk of intraoperative massive bleeding. Adequate management is challenging and inconclusive. CASE REPORT: We present two unusual cases with a diagnosis of GTD in advanced LLIEP. The first case had choriocarcinoma in cesarean scar and the second case had mole pregnancy in cervix. Both cases were managed with laparoscopy uterine artery ligations followed by transvaginal intrauterine curettage and vacuum aspiration with a small amount of surgical blood loss and then resumed regular menstruation. To understand the different surgical approaches and their potential advantages in managing such rare diseases, relevant cases in the literature were reviewed. CONCLUSION: Much attention should be paid to avoid massive bleeding at initial surgical intervention in patients with GTD in advanced LLIEP. This novel approach with combination of laparoscopic uterine artery ligations and evacuating curettage in selected patients is highly recommended to minimize surgical blood loss. The obvious advantages include technical feasibility, less surgery-related bleeding and potential fertility preservation.

The role of prolonged progestin treatment and factors predicting successful fertility-sparing treatment for early endometrial endometrioid adenocarcinoma.

OBJECTIVE: Fertility-sparing progestin therapy is highly effective in selected young women with endometrial cancer. In present study, we attempted to evaluate the role of prolonged medication and identify factors predicting successful treatment, and also assess fertility outcomes among young women with early stage endometrial endometrioid carcinoma (EC). STUDY DESIGN: We retrospectively reviewed clinical data from patients aged <45 years with well-differentiated EC at presumed stage IA (without myometrial invasion) who wished to preserve fertility. They were managed with oral progestin at Kaohsiung Chang Gung Memorial Hospital between June 2005 and June 2019. RESULTS: Forty-five patients were included with a median follow-up of 53.5 months (range 12-170 months). Forty-one patients (91.1%) had complete remission, the cumulative complete response (CR) rates at 3, 6, 9, 12, and >12 months were 17.7%, 48.9%, 60.0%, 68.9% and 91.1%, respectively. Among the 41 responders, 23 attempted to conceive and nine (39.1%) achieved pregnancy with 12 live newborn infants. Eleven (27.5%) responders experienced recurrence at a median of 22 months from CR (range 3-54 months). Multivariate Cox regression analysis revealed that non-diabetes (HR: 4.59; 95% CI: 1.62-12.98) and endometrial thickness <2 cm (HR: 0.39; 95% CI: 1.41-17.67) were significantly factors associated with treatment response. CONCLUSIONS: We concluded that prolonged oral progestin treatment was possible with a certain proportion of responders (24.4%) being responded after one year. Diabetes controlled on metformin and endometrial thickness <2 cm could be used as surrogate markers to predict better treatment response.

Monopronucleated (1PN) and tripronuclear (3PN) zygotes formation during assisted reproduction in POSEIDON group 4 patients: Emphasizing on polar bodies.

AIM: Abnormal fertilization (1PN/3PN) and its accompanying polar body (PB) conditions have been less discussed in poor ovarian responders. By observing the PBs, we analyzed the mechanisms of abnormal fertilization and aimed to explore the role of intracytoplasmic sperm injection/in vitro fertilization (ICSI/IVF) in POSEIDON group 4 patients. METHODS: An observational study. All fresh IVF/ICSI cycles from January 2018 to December 2019 were evaluated. The inclusion criteria were POSEIDON group 4. Fertilization and PB conditions were assessed 16-18 h post-insemination. Primary observation endpoints including normal fertilization, abnormal fertilization, and total fertilization failure rate. RESULTS: A total of 351 cycles involving 180 patients met the inclusion criteria. Of these, 15 cycles reported no retrieved oocytes. Finally, 336 cycles (IVF, n = 267; ICSI, n = 69) were included. A total of 1005 oocytes and 939 embryos were assessed. The mean female age was 40.8 years, and the mean AMH level was 0.6 ng/mL. The normal fertilization rate was 69.7%. The zygote distribution was 18.7% 0PN, 3.9% 1PN, 66.9% 2PN, 9.5% 3PN, and 1.0% ≥4PN. For 1PN zygotes, 59% were denoted as 1PN2PB. The mean 3PN rate was 8.9%. CONCLUSIONS: In POSEIDON group 4, most of the monopronucleated zygotes were 1PN2PB. Digyny (3PN1PB), due to failure to extrude the second PB, was the major cause of triploidy in which ICSI could not circumvent. The distribution of abnormally fertilized zygotes was similar in IVF and ICSI. To investigate the mechanisms of abnormal fertilization and assess whether ICSI is necessary, analysis of PB will provide important clues.

Risk of major adverse cardiovascular and cerebrovascular events in Taiwanese women with endometriosis.

BACKGROUND/PURPOSE: Endometriosis (EM) is linked to cardiovascular disease (CVD). However, whether this finding can be applied to the Taiwanese population remained unanswered. To investigate the association between EM and major adverse cardiovascular and cerebrovascular events (MACCE) and the therapeutic effect on the risk of MACCE in Asian women with EM. A retrospective population-based cohort study was performed. METHODS: A total of 17 543 patients with EM aged between 18 and 50 years were identified from a general population of 1 million Taiwanese after excluding diagnoses of major CVD and cerebrovascular accident (CVA) prior to EM. The comparison group (n = 70 172) without EM was selected by matching the study cohort with age, sex, and income and urbanization levels in a 4:1 ratio. RESULTS: During a median follow-up period of 9.2 years, Taiwanese women with EM had a significantly higher frequency of comorbidities, medical and surgical treatment, and MACCE than did their non-EM counterparts (2.76% vs 2.18%, P < .0001). After adjustment for comorbidities, patients with EM had an approximately 1.2-fold increased risk of MACCE (95% CI 1.05-1.29; P = .0053) and a higher cumulative incidence of MACCE compared with the normal population. Neither medical nor surgical treatment increased the risk of MACCE. Furthermore, medical treatment for EM appeared to be protective against MACCE. CONCLUSION: Taiwanese women with EM not only had a substantially higher frequency of comorbidities but also an increased risk of MACCE compared with the general population.

Sacrospinous ligament fixation with uterine preservation reduces the risk of anatomical recurrence in pelvic organ prolapse.

OBJECTIVES: This study investigated the effectiveness of sacrospinous ligament fixation (SSLF) and whether uterine preservation reduces the anatomical recurrence rate. METHODS: The medical records of 82 patients who received SSLF in a single medical center were reviewed retrospectively. Anatomical recurrence was defined as Pelvic Organ Prolapse-Quantification stage 2 or higher in any compartment. The primary outcome was intergroup analysis for uterine preservation and concomitant hysterectomy patients. The secondary outcomes were anatomical recurrence risk factors and the incidence of adverse events. Propensity score matching (PSM) was used to adjust for demographic differences between groups. RESULTS: The anatomical recurrence rate was 19.5%, and the retreatment rate was 11.0% (mean follow-up duration: 22.9 months). Cystocele was the most common recurrent compartment (17.1%). The uterine preservation group (n = 66) was younger, had lower parity, and had fewer stage 3 to 4 cystoceles and uterine prolapses than the concomitant hysterectomy group (n = 16). Shorter operation times (99.4 minutes vs 153.7 minutes, P = .002) and lower anatomical recurrence rates (11.5% vs 45.5%, P = .039) were found in the uterine preservation group before and after PSM. Previous pelvic organ prolapse surgery (hazard ratio 3.14) and concomitant hysterectomy (hazard ratio 4.08) were identified as risk factors for anatomical recurrence. The most common adverse event was buttock pain (14.6%), which resolved spontaneously within 4 weeks. CONCLUSIONS: SSLF is an effective surgical method using native tissue for pelvic reconstruction. Compared with concomitant hysterectomy, SSLF with uterine preservation reduces the anatomical recurrence rate.

Planned conservative management of placenta increta and percreta with prophylactic transcatheter arterial embolization and leaving placenta in situ for women who desire fertility preservation.

INTRODUCTION: The objective of our study was to demonstrate planned conservative management of placenta increta and percreta in a single tertiary center. METHODS: From April 2005 to July 2019, patients with placenta increta and percreta were managed conservatively at the Kaohsiung Chang Gung Memorial Hospital in Taiwan. The severity of placenta invasion was diagnosed by magnetic resonance imaging (MRI). After delivery of the neonate, prophylactic transcatheter arterial embolization (TAE) was performed immediately. The placenta was left in situ and prophylactic antibiotics were administered during hospitalization. The patient profiles, outcomes, and complications were retrospectively reviewed. RESULTS: Based on the MRI findings, twenty-one patients with placenta increta or percreta were included. With prophylactic TAE, the mean surgical blood loss was 854.7 ± 478.2 mL. The mean natural resorption time of residual placenta was 4.69 ± 1.65 months. Regarding maternal complications, 4 patients (19%) had delayed postpartum hemorrhage (PPH), 12 patients (57.1%) developed postpartum infections, 3 patients (14.3%) progressed to sepsis, 4 patients (19%) underwent surgical evacuation, and 4 patients (19%) underwent hysterectomy. No maternal mortality was reported. Main neonatal complications were prematurity and respiratory distress. Regarding fertility, 16 (76.1%) patients had return of menstruation, and one (4.7%) had a subsequent pregnancy resulting in a live birth. DISCUSSION: Planned conservative management with prophylactic TAE and leaving placenta in situ is feasible and safe for women with placenta increta or percreta who desire fertility preservation. Delayed PPH and postpartum infection are common complications after conservative treatment.

Serum ß-human chorionic gonadotropin profile and its correlations with ultrasound parameters in low-lying-implantation ectopic pregnancy in the first trimester.

AIM: Cervical pregnancy (CP) and cesarean scar pregnancy (CSP), defined as low-lying-implantation ectopic pregnancy (LLIEP), are rare conditions of aberrant implantation around the lowest portion of the uterus. This study aimed to illustrate the serum ß-human chorionic gonadotropin (ß-hCG) profile of LLIEP and to explore its implications with the clinical characteristics. METHODS: Women with LLIEP during the first trimester were retrospectively evaluated at a tertiary referral center from August 1999 to July 2016. Demographic and clinical data were recorded, including maternal age, gestational age (GA), serum ß-hCG level, maximal diameter of the gestational mass/sac (MDM/MDS) by ultrasonography and CSP implantation types. The serum ß-hCG level was measured on the day of ultrasound imaging. The significance of pretreatment the serum ß-hCG level and its correlations with the clinical characteristics were analyzed. RESULTS: A total of 88 LLIEP with 64 CSP and 24 CP was included. The mean GA at the time of diagnosis was 7 weeks (range, 5-12 weeks). The ß-hCG concentrations rapidly increased from GA 5 to 9 weeks and fluctuated thereafter. The ß-hCG levels correlated positively with GA and ultrasound MDM/MDS. In the CSP group, there was no difference in the ß-hCG level between superficial and deep implantation types. ß-hCG levels demonstrated no significant differences among simple and complicated LLIEP. CONCLUSION: This study established the serum ß-hCG profile in LLIEP in the first trimester. The exponential increase of ß-hCG levels was similar to that of normal intrauterine pregnancies. The ß-hCG levels were not associated with placentation complexity of CSP. Higher ß-hCG levels did not implicate less success in conservative surgical management.

Effects of uterine artery occlusion during myomectomy on ovarian reserve: Serial follow-up of sex hormone levels, ultrasound parameters and Doppler characteristics.

AIM: To evaluate the influence of uterine artery occlusion at myomectomy (UAO + M) on ovarian reserve based on serum sex hormone levels, ultrasound and color Doppler examinations. METHODS: In this cohort study, nine women with symptomatic uterine myomas underwent UAO + M were recruited. Each woman was assessed preoperatively and 3, 6 months postoperatively, through a serial of hormonal, ultrasound parameters and Doppler examination for ovarian stromal blood flow. The data were analyzed using generalized estimating equations. RESULTS: There was no significant difference in serum anti-Müllerian hormone (AMH) or follicle-stimulating hormone (FSH) levels before and 3, 6 months after UAO + M. The ovarian volume, antral follicle count (AFC) and ovarian stromal blood flow had significant changes in the right ovary. Ovarian volume and AFC significantly reduced at 3 months and recovered at 6 months postoperatively (P = 0.046, P = 0.019, respectively). Peak systolic velocity and end diastolic velocity significantly decreased at 3 months and leveled off at 6 months (P < 0.001, P = 0.001, respectively). Resistance index significantly increased at 3 months and decreased at 6 months (P = 0.037). A similar trend in ultrasound and Doppler findings was observed in the left ovary, but no statistical significance was found. CONCLUSION: UAO + M had no detrimental effect on ovarian reserve 6 months postoperatively based on AMH and FSH levels. AFC, ovarian volume and stromal blood flow were transiently decreased in 3 months and recovered in 6 months.

Mesh-related complications in single-incision transvaginal mesh (TVM) and laparoscopic abdominal sacrocolpopexy (LASC).

OBJECTIVE: Few studies have investigated the long-term impact of synthetic mesh reconstructive surgery for pelvic organ prolapse (POP) on patient outcomes. This study aimed to examine the incidence and risk factors of mesh exposure and the subsequent requirement for surgical interventions due to mesh-related complications. MATERIALS AND METHODS: This retrospective study was conducted from November 2010 to April 2018. We recruited women with Pelvic Organ Prolapse Quantification (POP-Q) stage 3 or 4 who underwent mesh reconstructive surgery for POP, and enrolled 487 women who received transvaginal mesh (TVM) and 110 women who received laparoscopic abdominal sacrocolpopexy (LASC). Assessments included mesh exposure rate and mesh-related complications requiring surgical interventions in both groups. RESULTS: In the LASC group, the overall mesh-related complication rate was 8.18% over a mean follow-up period of 18 months. Concomitant laparoscopic-assisted vaginal hysterectomy was associated with mesh exposure (OR = 9.240; 95% CI = 1.752-48.728). No patients in the concurrent supracervical hysterectomy group were exposed to mesh. In the single-incision TVM group, the overall rate of mesh-related complications was 3.29% over a mean follow-up period of 19 months. Concomitant total vaginal hysterectomy was also a risk factor for mesh exposure (OR = 4.799; 95% CI = 1.313-17.359). CONCLUSION: Preserving the cervix or uterus decreased the rate of mesh exposure in those undergoing TVM and LASC surgery. The overall rate of mesh-related complications was low after up to 8 years of follow-up.

Developmental potential of surplus morulas with delayed and/or incomplete compaction after freezing-thawing procedures.

BACKGROUND: Morulas with delayed growth sometimes coexist with blastocysts. There is still limited evidence regarding the optimal disposal of surplus morulas. With the advancement of vitrification, the freezing-thawing technique has been widely applied to zygotes with 2 pronuclei, as well as embryos at the cleavage and blastocyst stages. The freezing of morulas, however, has rarely been discussed. The purpose of this study was to investigate whether these poor-quality and slow-growing morulas are worthy of cryopreservation. METHODS: This is a retrospective, observational, proof-of-concept study. A total of 1033 day 5/6 surplus morulas were cryopreserved from January 2015 to December 2018. The study included 167 women undergoing 180 frozen embryo transfer cycles. After the morulas underwent freezing-thawing procedures, their development was monitored for an additional day. The primary outcome was the blastocyst formation rate. Secondary outcomes were clinical pregnancy rate, live birth rate and abortion rate. RESULTS: A total of 347 surplus morulas were thawed. All studied morulas showed delayed compaction (day 5, n = 329; day 6, n = 18) and were graded as having low (M1, n = 54), medium (M2, n = 138) or high (M3, n = 155) fragmentation. The post-thaw survival rate was 79.3%. After 1 day in extended culture, the blastocyst formation rate was 66.6%, and the top-quality blastocyst formation rate was 23.6%. The day 5 morulas graded as M1, M2, and M3 had blastocyst formation rates of 88.9, 74.0, and 52.8% (p < 0.001), respectively, and the top-quality blastocyst formation rates were 64.8, 25.2, and 9.0% (p < 0.001), respectively. The clinical pregnancy rate was 33.6%. CONCLUSIONS: The post-thaw blastocyst formation rate was satisfactory, with approximately one-half of heavily fragmented morulas (M3) developing into blastocysts. Most of the poor-quality morulas were worth to freeze, with the reasonable goal of obtaining pregnancy and live birth. This alternative strategy may be a feasible approach for coping with poor-quality surplus morulas in non-PGS (preimplantation genetic screening) cycles.

Association between hysteroscopic findings of previous cesarean delivery scar defects and abnormal uterine bleeding.

OBJECTIVE: The aim of the present study was to describe various hysteroscopic findings of previous cesarean delivery scar defects (PCDS), and evaluate the relationship between these findings and abnormal uterine bleeding. MATERIALS AND METHODS: This was a retrospective study including patients with abnormal uterine bleeding after a cesarean section. Transvaginal ultrasound and hysteroscopy were used to detect the origin of the symptoms, and the gynecological symptoms and hysteroscopic findings were recorded. Relationships between the hysteroscopic findings and abnormal uterine bleeding were evaluated. RESULTS: Ninety-six (82.8%) patients presented with intermenstrual bleeding. The most common findings of scar defects on hysteroscopy were increased local vascularization (74.1%) and oozing spots (47.4%). Increased local vascularization on the defect was significantly related to intermenstrual bleeding (p = 0.048). CONCLUSION: This study categorized different findings of PCDS under hysteroscopy. Increased local vascularization on the scar defect was significantly related to intermenstrual bleeding.

The effects of "unilateral midurethral sling cut down" in women with voiding dysfunctions after anti-incontinence surgery.

PURPOSES: Midurethral synthetic sling (MUS) placement via either the retropubic or transobturator route is the standard surgical procedure for women with stress urinary incontinence. However, a small portion of patients experienced voiding dysfunction after the surgery, which was debilitating to their quality of life. Our study was aimed at demonstrating the effectiveness of the unilateral sling cut down for post-midurethral sling (MUS) voiding dysfunction and, secondarily, at evaluating the changes in urodynamic parameters. METHODS: We retrospectively reviewed the charts of patients who received unilateral midurethral sling cut down for voiding dysfunction after an MUS procedure. The cut-down procedures were performed at the urethral meatus, in the 9 or 3 o'clock direction. Preoperative and postoperative subjective and objective parameters were compared to evaluate the outcome of the cut-down procedures. RESULTS: We selected 15 patients who underwent unilateral MUS cut down for voiding dysfunction after anti-incontinence procedures with various MUSs. The cut-down procedures were performed at a median interval of 7.1 months after sling insertion. The subjective results of the Patient Global Impression of Improvement (PGI-I) after the cut-down procedure showed an overall satisfaction of 93.33%. After the cut-down procedure, the median flow rate increased from 14.8 to 22 ml/s (P > 0.05), and the post-void residual urine volume decreased from 193.5 to 35.0 ml (P < 0.05). All patients attained continence after the cut-down procedures. CONCLUSIONS: Unilateral MUS cut down is effective in the management of voiding dysfunction after anti-incontinence surgery, with a low risk of recurrence of urinary incontinence.

Uterine endosalpingiosis: Case report and review of the literature.

OBJECTIVE: Endosalpingiosis rarely occurs in the uterus. We report a case and review literature to explore its current clinical diagnosis and treatment. CASE REPORT: A 31-year-old woman was admitted to the hospital for suspected uterine leiomyoma with cystic degeneration based on ultrasound and magnetic resonance imaging and surgical treatment. Laparoscopy revealed a large cystic mass protruding from the posterior uterine wall. The mass was resected, and a histologic examination showed that the cyst wall was lined with benign fallopian tube-type ciliated epithelium surrounded by normal myometrium, consistent with the diagnosis of endosalpingiosis of the uterus (also known as a Müllerian cyst). Currently, there are 18 cases (including ours) in the literature. Of these, two had a uterine malignancy, one endometrioid endometrial carcinoma, and another cervical adenocarcinoma. The age at diagnosis varied from 31 to 73, with a mean of 47 ± 8. The typical clinical manifestations were a palpable low abdominal mass, abnormal menstrual bleeding, and pelvic pain. Overall, 75% (12 of 16) of patients underwent a total hysterectomy, while 62.5% (10 in 16) had a concomitant bilateral salpingo-oophorectomy for nonmalignancy. No recurrence was reported. CONCLUSION: We describe the youngest patient with tumor-like uterine endosalpingiosis. The preoperative diagnosis is challenging because of its rarity. Most patients had a hysterectomy with castration, which may have resulted in overtreatment. Awareness of this lesion is necessary for the differential diagnosis of uterine and adnexal tumors. Review of relevant literature has shown a relationship between endosalpingiosis progression and cancer development, indicating an uncertain and complicated pathology.

Evaluating the efficacy of the single-incision uphold system for pelvic organ prolapse repair.

OBJECTIVE: The aim of this study was to assess the efficacy and clinical outcomes of pelvic floor reconstruction with transvaginal mesh of the Uphold™ Vaginal Support System (Boston Scientific Corporation). MATERIALS AND METHODS: This retrospective study reviewed the medical records of patients with pelvic organ prolapse stage 3 or 4 who underwent pelvic reconstructive surgery with transvaginal mesh of the Uphold™ Vaginal Support System from January 2015 to March 2017. Patients who were treated with laparoscopic sacrocolpopexy, transvaginal sacrospinous ligament suspension or other mesh kits were excluded. Assessments included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage, Urogenital Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire-7 (IIQ-7), urodynamic parameters, peri- and postoperative complications and symptoms. RESULTS: Of the 111 enrolled women, the anatomical success rate was 97.3% after a median 18.4 months of follow-up. POP-Q parameters, UDI-6 and IIQ-7 scores, maximum urine flow rate, and post-void residual urine all significantly improved after surgery. Complications included one case (0.9%) of infected hematoma, two cases (1.8%) of mesh exposure, three cases (2.7%) of recurrent prolapse, and 12 cases (10.8%) of transient urine retention. No bladder or bowel injuries occurred during surgery. CONCLUSIONS: Pelvic reconstructive surgery with transvaginal mesh of the Uphold™ System yielded satisfactory anatomical and urinary functional outcomes in a median 18.4 months of follow-up. IRB IDENTIFIER: IRB: 201700645B0.

Age is a major prognosticator in extremely low oocyte retrieval cycles.

OBJECTIVE: Clinical prognosis appears to be varied in females with poor ovarian response (POR), and poor responders defined by the Bologna criteria might not be sufficiently homogeneous. The aim of this study was to determine the major predictor of reproductive outcomes in extremely low oocyte retrieval cycles. MATERIALS AND METHODS: A cohort of fresh in vitro fertilization/intracytoplasmic sperm injection cycles (n = 858) was analyzed from January 2001 to September 2014. Females from whom zero, one, two, or three oocytes were retrieved following ovarian stimulation were examined. Univariate analyses were performed to determine the association of pregnancy rate with potential confounding variables. Multiple logistic regression analysis was subsequently performed to identify factors that affected the occurrence of pregnancy. RESULTS: The clinical pregnancy rate was higher in women aged < 40 years, long protocol, and high embryo score in univariate analysis. After adjusting for confounding factors in multivariate analysis, the maternal age [odds ratio (OR) = 0.91], primary or secondary infertility (OR = 1.99), number of matured oocytes retrieved (OR = 0.64), and score of embryos transferred (OR = 1.39) were significantly associated with the clinical pregnancy rate per cycle and per transfer. In the age subgroup analysis, POR females aged < 35 years significantly demonstrated the highest number of matured oocytes, embryo scores, and clinical pregnancy rates compared with POR females aged 35-40 years and ≥ 40 years. CONCLUSION: This study highlights the predictive value of maternal age and embryo quality on the probability of pregnancy in females with extremely low oocyte retrieval cycles. Young females with few eggs collected can still achieve acceptable pregnancy probability as long as they have good-quality embryos. Future randomized control trials for POR using the Bologna criteria should first stratify patients into different age groups.

Changes in the Prevalence of HBsAg and HBeAg: a Study of 8696 Parturients in a Well Vaccinated Area.

To elucidate the impact of a hepatitis B (HB) vaccination program on the prevalence of HB surface antigen (HBsAg) and HB envelope antigen (HBeAg) as well as the success rate of HBeAg clearance among parturients, we collected data on parturients who gave birth between 2000 and 2010, and recorded the HB status postpartum of those with positive HBeAg before birth. A total of 8696 parturients were enrolled, of whom 113 with prenatal positive HBeAg were invited back. The prevalence of HBsAg decreased over the study period, particularly in the vaccinated cohort, while there was no change in the prevalence of HBeAg. Foreign parturients had a higher HBeAg-positive rate and delayed HBeAg clearance, and those with a higher body mass index (>24 kg/m2) had earlier HBeAg clearance (51.9% vs. 23.9%, p = 0.005). Only 30% of the subjects who were positive for HBeAg before birth became negative 5 years after delivery. In conclusion, the downward trend in HB infection with more significance among vaccinated parturients reflects effective prevention and the impact of universal HB immunization. Nonetheless, aggressive follow-up is necessary for parturients who are persistently positive for HBeAg postpartum, as well as developing different public health policies for foreign parturients from endemic areas.